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Name *

Phone

Address

State

Company

Email

City

Zip

Regarding

Name of Employer

Unit Within Armed Services

Dates of Military Service

Were you denied pension contribution or credit for period of military leave?

Yes

No

Were you denied reemployment by civilian employer?

Yes

No

Were you discriminated against in hiring, termination, promotion, benefits, pay?

Yes

No

Were you retaliated against by civilian employer?

Yes

No

Were you denied veteran’s preference in hiring or promotion?

Yes

No

Were you denied health care or other employee benefits during military service?

Yes

No

Were you denied position due to service-related disability or asked about disability during application process?

Yes

No

Are there any other related issues you would like to tell us about?

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